Steve Carlson, Community Medical Center CEO

How do you believe the Affordable Care Act will affect the quality of care in America?

"I think a lot of the concerns today are not about quality, but about access. I don't think we will see a change, per se, but I think we will see a change in access.

That's where people may perceive that as a component of quality, relative to whether they get to seek care from providers they are comfortable with or have been treated with in the past."

Will I be able to see my same doctor that I am seeing now?

"Really, if you are getting your insurance from your employer, you won't see a change, unless, of course, your employer changes the plan design, or were the insurer they buy it from has a plan design change.

...but if you don't have insurance, if you qualify and are purchasing through the exchange, there you will see different products and you may see restrictions on which providers are participating in those exchanges.

So, it may be very possible that yes, you may or may not need to change providers."

Will face time with my doctor decrease?

"I am not hearing of people wanting to change the way they provide care. In my experience, providers pay a blind eye to payer source in how they provide care.

They have one standard, regardless of who the payer source is.

A lot of people are hearing that trauma centers could close. What do you think?

"I think it could make it more challenging for safety net hospitals. Community is a safety net hospital because we have a high medicaid load and part of the financing for the Affordable Care Act was a reduction in the pay rate for Medicaid patients, assuming we would see a further coverage of medicaid qualified patients as medicaid expanded, well, here in Montana and elsewhere, states decided not to expand medicaid and yet those dish cuts or medicaid cuts still go into place. So, perhaps safety net hospitals, may who are trauma centers might need to make cutbacks in their costs. It could affect the care they provide or the services they offer."

Will specialized clinics close?

"I'd be surprised if this resulted in individual clinics closing.

I think that it will result in some markets, (we're not seeing it here in Missoula, but) perhaps in some larger, urban markets, there will be restrictive networks.

So, patients who buy through the exchange may not have as much choice as they would if they bought through other products; other insurance plans."

"Where we are more likely to see more pressure on access is in primary care.

As coverage is expanded, more people have insurance.

They have the ability to seek that primary care in the physician's office, where, without insurance, they may have gone without are or ultimately got care in an ER.

Now, we are going to see it in a more cost effective setting, but it's very likely demand will increase. So, I think it will put additional pressures on our primary care physicians."

Will we have enough primary care physicians?

"It depends on developing more effective use of mid-levels, nurse practitioners, physician assistants. We very well may have over the long term, but we certainly have to change the delivery mechinism, as these new products demand different ways of delivering service."

Do you think some of your clients will say, I don't want a nurse practitioner, i want a full-fledged Doctor?

"I think they would be very happily surprised with the quality of care that can be provided by mid-levels todday.

What we need to understand is, those mid-level practitioners are really working hand in glove with the physicians, and it's that team that is taking care of them.

I have no problem myself seeing a mid-level for my primary care."

What concerns are you hearing from your physicians and specialists?

"I think the providers have the same concerns that the hospitals have as more and more of the payment shifts to government based, which is not paying us the full cost of providing that care.

It's making it more and more difficult for us to be able to stay in business.

The ability to cost-shift that to others just isn't there, nor should it be.

So, the economic challenges are really what is primary, I think, in many minds."

"Again, it's important for us to understand that when the healthcare industry, specifically the hospital industry got behind support for the Affordable Care Act, it was under the assumption that we woudl take the cuts in medicaid payments, and that would be balanced by increased coverage through medicaid expanstion.

Now that many states have decided not to expland medicaid, and the cuts are still going into effect, I think it's creating a real economic hardship, specifically on hospitals like Community that are safetynet hospitals; hospitals that have a disproportionatly high medicaid load. We need to do something about that.

We have talked to our legislatures relative to passing legislation to change that.

With the support of the Hospital Association, Washington is beginning to listen, and I am hopeful this error for unjust position we have today ultimately will be corrected."

What do you need Washington to do? Do you need more money?

"If you have decided you are not going to expand Medicaid, which we have decided here, then you can't impliment the dish cuts, or the medicaid cuts until that expansion has been reconcidered and hopefully embraced.

You have to have balance. These are very tight.

When hospitals operate, as we do at about a 2% margin, we don't have a lot of room for error.

so, when we thought we were going to have a balanced solution, we can't take the cuts until we get the opportunity to cover them in some way."

"Could we see fewer doctors here if that balance doesn't happen?"

"Ultimately, we have to reduce our costs and that could result in us rethinking what services we can afford to offer. So, yes, as in any business, if we don't have the economics to support it, Then we are going to have to make changes."

Does that mean eliminating a specialty, or having fewer doctors in that specialty?

"Many of the specialists in our market are independent and not employed by the hospital. Both hospitals are focused primarily in employing primary care physicians. Where would you see the cut-backs? I think you would see the cut-backs likely in in-patient services. Trauma centers like St. Pats may have to reconsider whether they can afford to continue to provide that service, if they are seeing reductions in reimbursement without any counterbalances.

So, I think it will be questions like that: can we continue to offer all the services that we've had. Do we have to eliminate some services, or do we have to reconfigure how those services are delivered?

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